Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.

CONTEXT: Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. OBJECTIVE: To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. DESIGN: Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. SETTING: Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. PATIENTS: Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). MAIN OUTCOME MEASURES: Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. RESULTS: No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05). CONCLUSIONS: In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

A north-south comparison of blood pressure and factors related to blood pressure in the People's Republic of China: a report from the PRC-USA Collaborative Study of Cardiovascular Epidemiology.

OBJECTIVES: To compare blood pressures in northern (Beijing) and southern (Guangzhou) Chinese population samples aged 35-54 years, males and females, urban and rural, and to assess the role of blood pressure-related traits in explaining north-south differences. DESIGN: Cross-sectional surveys were conducted in 1983-1984 of northern and southern populations employed in industry (urban) or farming (rural). METHODS: In the north samples were selected from the Capital Iron and Steel Complex (urban) and Shijingshan district (rural); in the south samples from the Guangzhou Shipyard (urban) and Panyu County (rural) were used. RESULTS: The number of subjects surveyed in north and south were 4706 and 4179, respectively: 1500 and 1052 urban males, and 717 and 914 rural males; and 1300 and 1061 urban females, and 1189 and 1152 rural females, respectively. Average systolic (SBP) and diastolic (DBP) blood pressures, were consistently higher in the north than in the south. SBP and DBP were significantly and independently related to age, body mass index, heart rate, use of antihypertensive drugs, serum triglycerides level, alcohol use (males only) and inversely to cigarette smoking. Northerners were older, taller, heavier and had higher body mass index and triglycerides level than southerners. With adjustment of SBP and DBP for blood pressure-related traits, north-south blood pressure differences decreased, but remained significant for urban males, rural males and rural females, with sizeable differences for rural samples in particular. CONCLUSIONS: North-south differences in blood pressure in these samples are accounted for only partly by north-south differences in the cited blood pressure-related traits. The role of other traits requires assessment.

Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin.

The Coronary Drug Project was conducted between 1966 and 1975 to assess the long-term efficacy and safety of five lipid-influencing drugs in 8,341 men aged 30 to 64 years with electrocardiogram-documented previous myocardial infarction. The two estrogen regimens and dextrothyroxine were discontinued early because of adverse effects. No evidence of efficacy was found for the clofibrate treatment. Niacin treatment showed modest benefit in decreasing definite nonfatal recurrent myocardial infarction but did not decrease total mortality. With a mean follow-up of 15 years, nearly 9 years after termination of the trial, mortality from all causes in each of the drug groups, except for niacin, was similar to that in the placebo group. Mortality in the niacin group was 11% lower than in the placebo group (52.0 versus 58.2%; p = 0.0004). This late benefit of niacin, occurring after discontinuation of the drug, may be a result of a translation into a mortality benefit over subsequent years of the early favorable effect of niacin in decreasing nonfatal reinfarction or a result of the cholesterol-lowering effect of niacin, or both.

Planning and implementation of large clinical trials.

The large-scale collaborative clinical trial has become an important activity in the biomedical research spectrum. It is the clinical trial that determines most precisely the efficacy of treatment of preventive regimens. These large studies, which usually cost tens of millions of dollars and use large numbers of research facilities, have a major impact on research and medical practice. Consequently, it is required that a number of factors be carefully assessed before any such study is undertaken. A formalized decision process has been developed by the National Heart, Lung and Blood Institute to aid in the formulation, design, conduct, analysis and dissemination of the results of clinical trials. This decision process, which provides a planning framework for the trial, is described here. The framework is constructed around three major decision points at which resources are committed: to plan the trial, to conduct the trial, and to terminate and disseminate the results of the trial.

Decline of coronary heart disease mortality in the United States.

Annual mortality rates for cardiovascular disease in the U.S. have declined steadily since at least 1968, with an accelerated rate of decline since approximately 1972. Although these trends have been seen in both men and women and in both Blacks and Whites, there have been relative differences in the rate of decline by region and state within the U.S. The relative importance of improved prevention vs. treatment in accounting for this decline has been discussed at length but not resolved, and efforts to gather relevant data are still being undertaken. Nonetheless, important changes have occurred in dietary habits with, for example, lower animal and higher vegetable fat consumption; in cigarette smoking rates, with especially important declines in middle-aged men; and in high blood pressure control, with improved levels in both genders and especially in Blacks, who have the highest rates.